Art of Service Delivery: Learning from Faith-inspired Health Care Providers

“In this clinic we are accommodated well and treated respectfully… We have the opportunity to converse with the health worker, describing the illness, and when we are mistaken or do not understand, we are not threatened. They help us locate the pain and they explain everything about the disease and how to treat it. They encourage us to speak and they try to give us confidence.” –Patient in Burkina Faso

At a time when many African countries may not achieve the health targets set forth in the Millennium Development Goals, the contribution of faith-inspired providers to improved health care is crucial. A recent World Bank study suggests that, while these providers’ market share and reach to the poor may be smaller than often assumed, they seem particularly good at serving their patients. Indeed, they seem to be experts in the science (or maybe in this case, the art) of delivery, a concept World Bank President Jim Kim has spoken of recently in several keynote addresses on achieving universal health coverage.

The Bank’s study provides illuminating evidence on the market share of faith-based providers, commonly believed to be responsible for a large share of the health services available in Africa. In a number of African countries, data are available on hospital beds provided by Christian Health Associations (CHAs) and the public sector (data on other private sector providers are harder to come by). As a share of the hospital beds provided by the CHAs and Ministries of Health, the CHAs often account for one-third or more of the available beds, which is indeed very large.

But when using data from household surveys, which include all private health facilities as well as traditional healers, chemical stores, pharmacists, and other health service providers, and when including countries where CHAs are not present, the region-wide market share of faith-inspired providers is smaller, of the order of 10%. Still, even if their market share is smaller than often claimed, the contribution of faith-inspired providers clearly remains significant.

Consider next the issue of reaching the poor. It is also often believed that faith-inspired providers reach the poor as a matter of priority, while private, secular providers reach mostly wealthier households. There is truth to this, but data from household surveys suggest that differences in beneficiary incidence between various types of providers are smaller than often believed and that none of the three types of providers (public, faith-inspired, or private secular) serve the poor more than the better off in absolute terms.

Especially for faith-inspired providers, this occurs in part due to a need for some level of cost recovery. As faith-inspired providers often receive only limited support from governments, they have no choice but to charge for care which may make it difficult for the poor to visit. Households often prefer faith-inspired facilities, but they cannot always afford them, even when the facilities make special efforts to make their services affordable.

Consider, finally, the quality of health services, which is arguably the most important issue. Data from household surveys suggests that faith-inspired providers enjoy higher satisfaction rates than both public and private secular facilities. This explains why it is often reported that patients are willing to walk long distances to visit faith-inspired facilities – a finding is supported by both quantitative and qualitative evidence.

What seems to drive the higher satisfaction rates with faith-inspired providers is the quality of the service provided and the respect with which patients are treated. As one patient said, “Human warmth is very present in this center. There is a true closeness between the patients and the sister and her colleagues. One is spoken to, touched and accepted.” Evidence shows that many faith-inspired providers work more closely with communities, and that they succeed in promoting health through preventive services as well as nutritional and educational programs.

In sum, while faith-inspired providers may have lower market shares than commonly believed, and while they may not always be located in poor areas or serve primarily the poor, they provide vital services that are seen by patients as being of higher quality than the services provided by other providers. The evidence clearly points to a major role played by these providers, but more importantly it calls for stronger public-private partnerships than are currently observed. In addition, mechanisms should be put in place so that other care providers can learn from those faith-inspired providers that seem to excel at the science – or perhaps the art – of delivery.

Comments

Quentin: Thanks for highlighting this issue. Two questions: Do we know why faith-based service providers deliver higher-quality service than, say, public providers? In "Working for God?", Reinikka and Svensson (http://onlinelibrary.wiley.com/doi/10.1111/j.1542-4774.2010.tb00551.x/abstract) attributed it to intrinsic motivation. Are there other explanations? Secondly, is it possible to scale up faith-based services from their low market share? If the reason for the better service is intrinsic motivation, it may not be possible to find enough providers with that motivation. To attract more workers, you may have to pay them more, at which point the cost-effectiveness advantage may disappear. Incidentally, these are questions we will be discussing in the February 28-March 1 conference on the 10th anniversary of the 2004 World Development Report, "Making Services Work for Poor People" ( http://go.worldbank.org/IMORKI2LC0 ).

Thanks for asking this. Both the survey data on satisfaction rates and in-depth qualitative interviews point to better service delivery by many faith-inspired healthcare providers. The qualitative data suggest that this is due to staffs being more attentive to patients, more respectful, and closer to the communities. These attitudes may be related in part to intrinsic motivation, but they are also related to a positive culture and systems that faith-inspired providers have in place to encourage and train staffs to place service to patients at the center of their work. We found somewhat similar results for faith-inspired schools in Africa (https://openknowledge.worldbank.org/bitstream/handle/10986/16391/9780821399651.pdf?sequence=1).

In the work on faith-inspired healthcare providers, we did not investigate in details how the providers train their staffs to encourage great service to patients. But in a study we recently did on Fe y Alegria schools in Latin America, we looked at how the schools trin teachers to be responsive to the need of their students (https://openknowledge.worldbank.org/handle/10986/16375). Motivation plays a role, but the role of accountability and the dedication of the school's management to foster a culture of service is probably even more important.

Overall, the message is that while is not easy, fostering such attitudes can be done, and the experience of faith-inspired providers is useful to better understand how. The message of the studies is not necessarily to scale up provision by faith-inspired providers, but first to at least fund their work properly when it is of high quality (this is often not done by governments), and next to learn from their successes, and see indeed how they can be replicated in other types of schools.

The questions that you both raise about quantity, quality, roles in capacity development, and reach are all vitally important questions as we work to improve health care in Africa (and of course beyond). At Georgetown and the World Faiths Development Dialogue (WFDD - the NGO born in 2000 in the World Bank) we continue to wrestle with the questions of what we know, why it matters, and what it means for policy and practice. We had the chance (in partnership with the Tony Blair Faith Foundation) to undertake a thorough stock-taking of the state of knowledge and understanding on faith and health; the results are summarized here http://berkleycenter.georgetown.edu/wfdd/publications/health-in-africa-and-faith-communities-what-do-we-need-to-know in a policy brief that summarizes the full report.

In an environment where knowledgeable actors use widely different figures and advance widely varying assertions, Quentin's work to separate fact from rough estimate or assumptions colored by belief more than fact represents a major advance. His mining of household survey data offers important new insights.

Looking towards a research and policy agenda, a few suggestions emerge from our own reflections. First, there are huge variations by country, colored by colonial history, post independence approaches to public service and private roles (including faith), outside resources available, and so forth. Knowing a country's history and the current roles in health (and in other sectors) of the variety of religious actors is critically important. Second, religious roles and institutions are ferociously complicated and they are dynamic. Appreciating differences among but also within religious traditions and denominations is vital. And we know too little about how roles are changing. Third, there are significant risks of missing both superb and negative experience because the evidence base on faith-inspired work is so patchy. Learning more can enhance efforts to improve service quality. And fourth, the tendency to isolation and separate paths that is a general characteristic of many faith-inspired health approaches and organizations goes against the goal of aid harmonization. Working for better knowledge, global and granular, and bringing voices and experience into strategy and policy debates makes eminent sense. It is not a simple matter to bring faith voices to the policy tables at different levels (global to local) but it is nonetheless important to do so.

I fully agree that there are substantial differences in the role of faith-inspired healthcare providers between countries. The Christian Health Associations (CHAs) for example have a strong presence in many Anglophone countries, and a smaller footprint – when they exist – in much of Francophone Africa, and this is related in part to the legacy of the colonial heritage. Within Anglophone Africa, there are also large differences, not only in market share, reach to the poor, cost, and satisfaction, but also in terms of the recognition granted to faith-inspired providers by government. Ghana stands out as one of the countries where the partnership between the CHA and the government is strong. As you point out there are also differences between faith traditions, and we know much less about Islamic providers than Christian ones. Finally, you note that faith-inspired healthcare providers are a heterogeneous group – with some providing service of great quality and others less so. It is to provide such context that our three volumes study combines multi-country analysis with detailed country case studies.

In terms of future agenda, all the points you mention are clearly worth pursuing. I would like to add three more. First, as I mentioned it to my reply to Shanta, if we want to operationalize this work, we really need to understand better why some faith-inspired providers do so well, so that others can learn from their experience. What’s in the black box? Apart from intrinsic motivation, what are the systems and management mechanisms that foster a culture of service among these providers? Second, faith leaders have a strong influence on the population’s behaviors, including health-related behaviors or behaviors with health consequences. We need to try to better harness this influence for improving health outcomes. Third and finally, we need to better understand the role of small informal faith-inspired initiatives from congregations and other community groups. While we have made progress in understanding the role of larger facilities-based faith-inspired healthcare, we still know little about small-scale and faith-inspired informal providers of care and healing.